Improvement in documentation of intake and output chart
Intake and Output (I/O) records in hospitals were often found to be incomplete and illegible. The form used to record I/O is not user-friendly — i.e., they feature miniscule boxes, ‘total’ lines that do not correspond with shift changes and lack of instructions. Complaints often received from...
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Main Author: | |
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Format: | Article |
Language: | English |
Published: |
Universiti Kebangsaan Malaysia
2011
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Online Access: | http://journalarticle.ukm.my/3549/1/special%2520issue%25202011_22.pdf http://journalarticle.ukm.my/3549/ http://www.ijphr.ukm.my/ |
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Institution: | Universiti Kebangsaan Malaysia |
Language: | English |
Summary: | Intake and Output (I/O) records in hospitals were
often found to be incomplete and illegible. The form
used to record I/O is not user-friendly — i.e., they
feature miniscule boxes, ‘total’ lines that do not
correspond with shift changes and lack of
instructions. Complaints often received from
Specialists & Doctors regarding calculation errors or
no totalling of I/O. Moreover, Nursing Sisters
objective rounds often saw incompleteness of I/O
chart. This study aims to identify the types of
mistakes in recording the existing I/O chart. The
second aim is to find out whether shift totalling of
I/O chart helps in reducing mistakes. We try to
determine whether the identified mistakes were
repeated in the new I/O Chart. This study was
conducted from October till December 2010 in 9
selected wards in Sibu Hospital. Data collection was
divided into 3 phases. A pre-implementation audit
using a checklist was carried out. The compliance
rate of completeness of documentation of I/O Chart
was 63%. A one month trial of new I/O chart was
being done in the selected 9 wards. Post
implementation audit showed a significant
improvement of compliance rate (88%). Feedback
from health care workers (N=110) showed that, 89%
of doctors (n=17) and 60% of nurses (n=93) in the
sample prefer to use the new format as more
practical and relevant to the changing shift of nurses
and doctors’ ward round. It is suggested to
implement the new format to increase compliance
rate of documentation of I/O charting. Briefing
should be given to nurses periodically and the new
format should be introduced to nursing students in
nursing colleges. |
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